Learning from Neighbourhoods in Practice: A Virtual IHI Session with Cornwall and the Isles of Scilly

 3rd June 2026

By Robin Campbell, Raj Shah and Jo Moore

In March 2026, Bedfordshire Community Health Services (BCHS) hosted a virtual Institute for Healthcare Improvement (IHI) learning session, bringing together colleagues from across Bedfordshire with neighbourhood health leaders from Cornwall and the Isles of Scilly.

Facilitated by Hugh McCaughey, former National Director of Improvement at NHS England, the session offered an opportunity to learn from established neighbourhood models while reflecting on local progress and priorities. With increasing national focus on neighbourhood health and prevention, the session created space to consider how joined-up, community-based care can be further developed for people living with frailty.

Participants came together around three core questions:

• What gets in the way of delivering truly joined-up neighbourhood care for people living with frailty — and what would it take to remove those barriers?
• What does excellent neighbourhood-based frailty care look and feel like — for staff, patients, carers and communities — and which parts of that vision could we start building tomorrow?
• Where are we already seeing promising neighbourhood-style working, and how can we build on this to accelerate progress?

Learning from Cornwall: Relationships, Clarity and Purpose

Colleagues from Cornwall and the Isles of Scilly shared their experience of developing neighbourhood-based health and wellbeing across a large and diverse system, including 16 emerging Integrated Neighbourhood Teams aligned broadly to Primary Care Network footprints.

Their approach centres on neighbourhoods as the organising unit for delivery, alongside a shift away from reactive models of care towards more proactive, population-based approaches—particularly for people living with frailty and complex needs.

A consistent message was that success depends not only on structures, but on culture and shared commitment. Partners across the system have aligned around a common vision, with a focus on collaboration, collective accountability, and reducing duplication.

This is supported by clear system leadership, dedicated change capacity, and a test-and-learn approach, developing neighbourhood models in practice, evaluating impact, and scaling what works over time. Proactive frailty care, including risk stratification, multidisciplinary team working and earlier intervention, was highlighted as a key area of focus.

Understanding the Barriers: A System Perspective

Through breakout discussions, participants explored the realities of delivering joined-up care in Bedfordshire.

A key theme was the challenge of fragmented and siloed services, often compounded by overlapping initiatives and unclear ownership. These factors can make it difficult to coordinate care effectively and create confusion for both staff and service users.

Participants also reflected on the lack of shared understanding of how the system currently operates compared to the intended neighbourhood model, alongside pathways that remain difficult to navigate.

Other commonly identified barriers included:

• Workforce capacity and time constraints
• Limited clarity of leadership and accountability
• Challenges with digital interoperability and access to data
• Funding arrangements that do not always support prevention and community-based care.

What Good Looks Like: A Shared Ambition

Alongside these challenges, there was strong alignment on what excellent neighbourhood-based frailty care should look and feel like.

Participants described care that is holistic, person-centred and inclusive, where people feel listened to, understood and supported as individuals rather than moving through disconnected services.

There was a clear vision of:

• Simple, easy-to-navigate pathways, with clarity on who to contact and how to access support
• Accessible, consistent communication, tailored to diverse communities
• Integrated physical and mental health support, recognising the complexity of frailty
• A supported and skilled workforce, able to deliver high-quality, compassionate care

Importantly, this vision extended beyond services to include carers, families and communities as active partners in care.

From Vision to Action: Where We Can Start

A strong focus of the session was translating discussion into practical next steps.

Participants identified opportunities to:

• Strengthen communication and produce clearer, more accessible information for patients and carers
• Simplify and reframe how neighbourhood health is described, making it more meaningful and understandable
• Build on existing examples of good neighbourhood working and adapt these across local areas
• Strengthen collaboration across services, particularly between physical and mental health teams
• Use data more effectively to understand population need and support proactive care

There was also a clear appetite to adopt a test-and-learn approach, developing and refining models in practice while avoiding duplication and unnecessary complexity.

Building Momentum

The session highlighted both the progress already being made and the opportunity to go further. It created space for shared reflection, surfaced common challenges, and developed a clearer, collective understanding of what neighbourhood-based care could look like in Bedfordshire.

The insights captured through the breakout discussions have been collated and will be used to inform the next phase of the Bedfordshire Neighbourhoods Programme. Further updates will follow as this work progresses.

Feedback from the session was overwhelmingly positive. With over 50 attendees from across the system, including service users, clinicians, voluntary sector partners, social care, acute providers and system leaders, there was a strong sense that the session had been both energising and inspiring. Colleagues reflected that hearing Cornwall’s experience brought neighbourhood working to life and reinforced what is possible when partners align around a shared purpose.

Importantly, the session has already prompted teams to think differently about how they work together day-to-day. Participants identified opportunities to widen existing collaborative spaces, involve a broader range of partners, and take practical steps now to strengthen joined-up working within and across neighbourhoods.

More than a standalone event, the session marks another step in building a shared direction — one grounded in collaboration, learning and a continued focus on improving outcomes for people and communities.