Governance infrastructure for neighbourhood health
Because handovers are where care fails
Neighbourhood health brings together general practice, community services, mental health, social care, and the voluntary sector around the same patients.
Every collaboration creates a handover. Every handover creates risk unless it is governed.
The NHS has no shared infrastructure to govern handovers across organisational boundaries.
What is Neighbourhood Health in the NHS?
Neighbourhood health refers to the delivery of coordinated care across general practice, community services, mental health, social care, and the voluntary sector at a local population level. In the NHS, this is typically organised through Primary Care Networks and place-based Integrated Care System arrangements.
It shifts care closer to home, increases collaboration across organisations, and relies on frequent handovers of responsibility between teams. This is not an integration problem. It is a governance problem that integration alone cannot solve.
The Seven Flows define the conditions that must hold for these handovers to be safe, explicit, and auditable.
Every collaboration creates a handover. Every handover requires governance.
What clinicians notice when handovers are governed
When governance is built into handovers rather than added afterwards, day-to-day work feels different.
- You can see what other teams are doing with the same patient
- You know who is responsible when something needs action
- You stop repeating assessments that have already been done
- You can share information without guessing whether it's allowed
- Escalations reach a named team or person, not a generic inbox
- Discharge information arrives before the patient does
Neighbourhood health does not reduce handovers. It multiplies them.
Every time a patient moves between teams, systems, or organisations, responsibility must transfer. In neighbourhood health, these transfers happen constantly across GPs, community nurses, mental health practitioners, social workers, and acute services. Each one is a potential failure point.
GP, district nurse, social worker, mental health practitioner. All involved, none clearly leading. Responsibility diffuses until it belongs to no one.
Sent is not received. Received is not read. Read is not actioned. The handover looks complete. It isn't.
Assumptions fill the gap where explicit handover should be. They work until they don't. When they fail, they fail silently.
Consent to one organisation is not consent to the neighbourhood. Lawful basis does not transfer automatically across a handover.
These are not edge cases. They are the daily reality of integrated care delivered on infrastructure designed for institutional boundaries.
The problem is not that clinicians fail to collaborate. The problem is that the systems they work in have no way to make handovers explicit, governed, and auditable. The Seven Flows exist to close that gap.
When a patient moves from acute discharge to community care, from GP to mental health, from social care to primary care, the governance should follow. It doesn't. Because the infrastructure doesn't exist.
This is not a future problem. It is happening now.
Neighbourhood health is already operating at national scale without national governance infrastructure. It is how primary and community care is being delivered across England today: unevenly, under pressure, and without the substrate to make handovers safe.
Around 1,250 Primary Care Networks are now responsible for neighbourhood-level delivery. Integrated Care Systems commission shared services across place. Community providers are expected to coordinate routinely with general practice, acute trusts, mental health, and social care.
The policy shift has already occurred. Delivery is live. What has not kept pace is the governance infrastructure required to make this safe.
~1,250 PCNs delivering neighbourhood-level care today
Place-based commissioning now the default operating model across England
The 10 Year Health Plan accelerates the shift of care into community and neighbourhood settings
Handover pressure is increasing faster than governance
The forces driving neighbourhood health are also multiplying handovers, and with them, clinical risk. Patients now move more frequently between general practice, community teams, acute services, mental health, and social care. Each transition creates a handover. Each handover introduces uncertainty unless it is explicitly governed.
At the same time, the system's capacity to absorb coordination work is shrinking.
More transitions
Patients move between settings more often, across more organisational boundaries, for the same episode of care.
Faster discharges
Reduced length of stay leaves less time to coordinate follow-up, clarify responsibility, or resolve ambiguity before transfer.
Thinner teams
Workforce pressure reduces the informal coordination that previously compensated for weak infrastructure.
Less slack
Safety margins that once absorbed error (time, familiarity, continuity) have eroded.
Local workarounds (spreadsheets, phone calls, shared inboxes) are being stretched beyond their design limits. They function by goodwill and personal knowledge, not by structure. They work until they don't.
When they fail, the failure is rarely immediate or visible. It emerges later as a missed follow-up, an unacknowledged alert, or an assumption that never should have been made.
The pace of neighbourhood delivery is increasing faster than the system's ability to govern the handovers it creates. Without explicit governance infrastructure, pressure does not just increase workload. It amplifies risk.
This is structural, not a failure of effort
The absence of neighbourhood governance infrastructure is not because no one tried. It exists because NHS digital systems were designed for a different care architecture, one where responsibility sat inside institutions, not between them.
Over the past decade, digital programmes have significantly improved delivery within organisations. Electronic patient records, shared care records, and integration engines all optimise activity inside defined boundaries.
But neighbourhood health changes the unit of care. Responsibility now moves across organisations, teams, and settings, and with it, risk.
When that movement happens, at discharge, referral, escalation, shared monitoring, governance does not reliably follow. Handovers become implicit, responsibility becomes assumed, and safety depends on goodwill rather than structure.
Neighbourhood health does not fail because teams cannot collaborate. It fails when collaboration is asked to carry governance it was never designed to hold.
Systems designed for institutions
EPRs, PAS, and GP systems assume a single organisation owns each episode of care. They are optimised for internal workflows, not for shared responsibility.
Governance anchored to legal entities
Data governance, clinical safety, and accountability are structured around organisations, not around patients moving between them.
Programmes optimise delivery, not invariants
Digital transformation has focused on efficiency and access within settings. The invariants required for safe handover were not enforced across settings.
Seven invariants that must hold at every handover
The Seven Flows do not create new processes. They make handovers explicit, governed, and auditable. Each flow exists because a specific type of handover failure happens without it.
These seven flows recur in every serious handover failure we see, regardless of pathway, setting, or vendor.
The Seven Flows are necessary conditions for safe handover. They do not replace clinical judgement or local pathways. They make them governable.
Identity
The handover failure: "Which John Smith?" Records don't match, identifiers don't travel, the wrong patient gets the wrong information.
What this flow stabilises
Trusted identification of patients, practitioners, and organisations, maintained across every handover, regardless of which system is involved.
The guarantee
Every clinical action is attributable to a verified patient, a verified practitioner, and a verified organisation, even when the patient moves across settings.
Explore all Seven Flows in detailWhere to go next
System oversight without centralisation
Neighbourhood health shifts responsibility across organisations, but accountability still sits at system level. The Seven Flows provide governance infrastructure that lets responsibility remain distributed, while making handovers visible at system level.
- Visibility of risk across neighbourhood handovers
- Assurance without operational micromanagement
- Evidence for CQC, NHSE, and internal governance
Participate without inheriting unmanaged risk
Neighbourhood health brings community providers into shared responsibility for patients, often without clear boundaries on what you own and when responsibility transfers.
- Clear ownership at discharge, escalation, and follow-up
- Shared care without assuming unseen liability
- Evidence of safe handover when things are reviewed
Make integration safe without rebuilding
Care now flows across organisations, but digital governance is still anchored inside them. The Seven Flows define governance invariants that sit above existing systems.
- Integration without replatforming
- Clear governance patterns for shared pathways
- Evidence for DCB 0129/0160, IG, and audit
Monitoring without escalation ambiguity
Remote monitoring extends care beyond organisational boundaries, but it also creates new handover points: from device to service, from signal to judgement, from alert to action.
- Clear ownership when thresholds are crossed
- Escalations that reach a responsible team
- Safe transition between monitoring and intervention
Components that make the Seven Flows real
The Seven Flows describe what must hold true for neighbourhood care to be safe. These components exist to enforce those conditions in practice, across organisations, systems, and care settings, without changing how clinicians deliver care.
This is infrastructure, not an application. There is nothing new to "log into". It operates beneath existing tools so that handovers are governed by default.
FHIR Cube
Maintains a longitudinal view of patient state across organisational boundaries, without centralising records. Governance, identity, consent, and provenance travel with each query.
FHIR Plane
Provides a shared control plane for neighbourhood care. Governs how information, requests, and responsibility move between systems, enforcing identity, consent, provenance, and intent at the moment of exchange.
Hazards Engine
Provides continuous clinical safety oversight across distributed teams. Hazards are identified, tracked, and evidenced across handovers, supporting DCB 0129/0160 obligations.
SteadyTrace
Governs the flow of device and monitoring data into neighbourhood care pathways. Signals are validated, contextualised, and routed with explicit escalation ownership.
Incremental adoption, not big-bang programmes
No multi-year implementations before first value. We start with one flow, one pathway, one neighbourhood. Evidence before expansion.
Discovery
Map your neighbourhood model. Identify highest-risk handover points. Define success criteria.
First Flow
Deploy one flow for one pathway. Prove governance works. Generate evidence.
Extend
Add flows, add pathways, add organisations. Scale what's working.
Embed
Governance becomes infrastructure. The substrate your neighbourhood model runs on.
Glossary
- Primary Care Network (PCN)
- Groups of GP practices working together with community, mental health, social care, and voluntary sector organisations to deliver coordinated care at neighbourhood level. Typically serving 30,000-50,000 patients.
- Integrated Care System (ICS)
- Partnerships of NHS organisations, local authorities, and others responsible for planning and delivering joined-up health and care services across a geographic area.
- Handover
- Any point where clinical responsibility, patient information, or care activity transfers between teams, organisations, or systems. Each handover creates risk unless explicitly governed.
- Clinical Governance
- The framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care.
- DCB 0129 / DCB 0160
- NHS Digital clinical safety standards. DCB 0129 applies to manufacturers of health IT systems. DCB 0160 applies to health and care organisations deploying those systems.
- FHIR (Fast Healthcare Interoperability Resources)
- An international standard for exchanging healthcare information electronically. UK Core FHIR R4 is the NHS-specific implementation.
Building neighbourhood health infrastructure?
We work with ICBs, community providers, and PCNs who recognise that integration without governance creates new risks. Start with a conversation.
Book a discovery call