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Delivering Community Nursing in Neighbourhoods

Over the past two years, The Adult Community Nursing Team has undergone remodelling work to deliver their service through eight Neighbourhood Nursing Teams alongside a new Single Point of Access (SPA). Moving from larger cluster localities to eight Neighbourhood Teams has been beneficial in providing smaller and more multiple teams, able to focus on the needs of their local populations.

There is now one central point for triaging referrals to the SPA clinical staff who can carry out initial assessments for patients new to the service and manage short episodes of care; like blood tests and post-operative wound care. This means that those patients requiring longer term care can be triaged or transferred to their relevant Neighbourhood team so the nursing team can really get to know their local patients and their holistic needs. They also have a good understanding of local services & practitioners who can support them in their care.

Key Leads:

Dr Shaine Mehta -Quality Improvement Clinical Lead GP Confederation & Diabetes Lead in City & Hackney

Shanaz Begum – Health & Wellbeing Coach, Shoreditch Trust


  • Although it was challenging to support the team through changes in roles, teams and processes, restructuring has meant managers can better identify specific Neighbourhoods with high demand and can distribute work evenly across the borough to prevent staff burnout.
  • The new Single Point of Access has made it easier for management to collect data from one central place on the nature of their referrals (who they’re coming from and what for) meaning they can better plan the service.
  • Having smaller teams with dedicated budgets works well both for GPs who now have a few local named contacts who they know and can easily contact.
  • Neighbourhood Multi-disciplinary meetings have been great spaces for nurses who cover that patch to get the expert advice they need from other professionals involved in a patient’s care, as well as pulling in specialist advice quickly where necessary.
“Working in Neighbourhoods we’ve noticed the difference that the community navigation roles employed by our local GP networks (known as PCN’s) can make. They allow us to focus on clinical healthcare knowing that another professional such as a social prescriber can take the time to support residents with their social issues.”
Want to learn more?     Get in touch  

Health & Wellbeing Coach Improves take up of Weight Management Programme at local GP practice

Southgate Road Medical Centre in Shoreditch Park and City Neighbourhood saw the pandemic significantly impact patient’s levels of physical activity and ability to manage their weight. In response the GP Practice aimed to increase the amount of referrals to North East London NHS’s Digital Weight Management programme.

In order to make sure as many referrals as possible were successfully taken up, additional wraparound support for patients was brought in. The GP Practice trialled the use of a local Health & Wellbeing (H&W) Coach to initiate contact with patients at the surgery who had diabetes or hypertension who were identified as being overweight. The intention was that having a professional H&W coach start a conversation about weight management with a target group of known patients, would mean the individuals may feel more informed and confident about accessing weight management support.

Key Leads:

Dr Shaine Mehta -Quality Improvement Clinical Lead GP Confederation & Diabetes Lead in City & Hackney

Shanaz Begum – Health & Wellbeing Coach, Shoreditch Trust


  • The practice has the highest referrals to Digital Weight Management (March 2022) and accounts for 25.9% of all practice referrals from City & Hackney (October 2021).
  • 40% of patients accepted referral to a weight management programme following a consultation with a H&W Coach
  • For patients, being informed that somebody will call them about weight management helps them to feel prepared and gives the coach a better opportunity to spend more time on talking about the programme in-depth if asked.
  • Calling at a time not too early or late in the day and sending a text with a link to the Digital Weight Management Programme information in advance was useful for patients to think about before a call
' It has been rewarding learning that there was a high uptake of the Digital Weight Management service since I called clients. This shows that there is a demand for the service. I enjoyed talking to people about their health and how they would like to make it better. Patients were much more likely to show interest in the programme having had it suggested by a GP or other health professional and being offered a call back. It made them feel prepared to spend some time discussing and asking questions about the programme" - Shanaz Begum - Health & Wellbeing coach, Shoreditch Trust
Get in touch to find out more     Get in Touch  

Neighbourhoods Mental Health Teams

Whole person approach to mental health

Neighbourhoods Mental Health Team was developed to support people who have serious mental health care needs, as well as wider social factors that may be impacting their life. The 8 Neighbourhood teams take a multi-disciplinary and trauma-informed approach, involving a broad range of support and expertise so that they can consider all the health and social care factors and complexities impacting on someone’s mental health.


  • Previously referrals would have come through a central assessment team on a weekly basis. Now each Neighbourhood team looks at their specific area’s referrals and follow up at a daily meeting.
  • The range of groups and activities in each Neighbourhood are specially curated, working with the local voluntary sector. This includes social activities, trauma-informed and psycho-educational groups, and sports.
  • Working on an open access basis means once you are successfully referred you become a ‘member’ of the service and can access support for up to 2 years without having to be re-referred. This means you can quickly get support if your mental health starts to deteriorate.
  • More partnership working is happening between mental health teams and local support services.
"You never rushed me when I spoke to you on the phone and you were always so supportive, kind and understanding. You helped me get into my Tai Chi classes by helping to get my lessons funded. I was able to gain the strength to help my son through his special needs issues and depression also". - Resident
Want to learn more?     Get in touch  

Hackney Playbus in Neighbourhood Forums

Hackney Playbus run stay and play sessions for families with children under five. The charity regularly attends Neighbourhood Conversations in all eight Neighbourhoods to link up with local services and people and learn about new opportunities for them to collaborate with other services to bring families’ support to their doorstep.


  • Neighbourhood conversations have provided a dedicated space to learn about what other activities and events are going on in the Neighbourhoods.
  • Accessing services can be difficult. By linking in with new services at Neighbourhood Conversations and bringing them to the community in the bus makes them more accessible.
  • Grant funding from Neighbourhoods to renovate the bus has improved its exterior and created an even more interactive space for the children.
"The Neighbourhoods programme is about bringing people together. Neighbourhood conversations are great for making connections, it's so good to hear about what work is going on in the local Neighbourhoods we deliver in and see how we can work together!"
Want to learn more?     Get in touch  

Children's Social Prescribing pilot

Accessible services for children and young people

Well Street Common Primary Care Network appointed a Social Prescriber role to support children and young people (age 0-25) and families as a whole to access local services and support.

The experienced Social Prescriber can create personalised action plans for individuals, and has begun working with local schools to better connect them with local health, social care and voluntary sector support, and act as a link between the schools and GPs as necessary. 


  • Families appreciate direct access to support rather than navigating a range of local services alone
  • Some families feel more comfortable accessing this support since the role has no affiliation with social services
  • Families working with the Social Prescriber in the medium term experience increase in self-confidence, motivation and general wellbeing
  • Parents and carers report being listened to, and supported to engage with services including social care where necessary
  • Children and young people are made aware of the local activities available which are relevant to their interests
“The Social Prescriber helped me with a grant application and I am now also going to the gym three times a week. I also found out about local holiday clubs for my children which they love.” - Client
Want to learn more?     Get in touch  

Unity Festival

Bringing communities together after isolation

Working with the local authorities, donations and funding from the Neighbourhoods grant, the Newington Green Alliance in collaboration with Minis Kardes organised the ‘Unity Festival’ to bring their community together after pandemic restrictions eased. 

The festival celebrated the diverse area by hosting music and food from the different cultures in Newington Green, and brought a great sense of community cohesion. 


  • Neighbourhoods funding provided budget towards the stage, and advertising
  • The Neighbourhoods Conversation provided a forum to advertise and collaborate with other organisations and residents
  • The event provided an opportunity to bring local people together in celebration and mourning following the first 18 months of the pandemic
  • New connections have been fostered to support further collaboration and sharing of cultures and resources in the area
"It was a wonderful day. Even the weather participated! I was especially moved to hear local residents say "this really feels like community" and others asking to have the event annually, monthly or even weekly!"
Want to learn more?     Get in touch  

Interview with Polly, Neighbourhood Forum facilitator for Well Street Common and Hackney Marshes

Veryan, Programmes Manager (VCS Neighbourhoods), interviews Polly, Neighbourhood Forum facilitator for Well Street Common and Hackney Marshes.


How did you first get involved in Neighbourhood forums?

I was working as community development worker for Wick Award, and was very aware of community health issues. When I heard about the first plans for the forums in the form of a pilot for Well St Common, I wanted to get involved.

Wick Award is a small but key community organisation in Hackney. Wick Award is led by Hackney Wick residents who really know their neighbourhood and are committed to working together to make good things happen. I’m the only paid worker, there are 12 local residents on our Partnership Board, and our chair is a former Ward Councillor, Nick Sharman. We work closely with other community organisations, for example, Hackney Quest is our main delivery partner providing brilliant youth services in the ward. Our approach is built on the findings of community research that we have undertaken ourselves. We support a range of community activities addressing isolation. We have a community funding pot to make money available to Hackney Wick residents set up their own initiatives to benefit residents.

What was it like in the early days of the pilot? 2018

The programme coordinator from HCVS took a lot of care to connect with everyone possible in Well St Common Neighbourhood in order to involve diverse groups and organisations, and she really took the time to explain the full potential of the forums. There were some big initial meetings with representatives from local organisations including Hackney Playbus, Hackney Carers Centre, Citizen’s Advice, Shoreditch Trust, and Age UK’s Older’s People’s Reference Group. There were wide conversations and a lot of mapping work was done, it was a very collaborative process. A lot of effort made to make it truly representative for residents, and we talked in detail to establish decision-making processes. People were very positive and keen to have a meaningful voice, to have a say and make sure local health inequalities were flagged and responded to. When Covid happened, meetings ceased initially as everyone’s resources were diverted, then online forums started up but these were quite challenging with so many people wanting to join and get involved, so it was much harder to make progress during this time. Eventually we were able to restart in person forums which was a relief.


Why is the work you’re doing so important?

The forums are a way for local residents to work with voluntary sector organisations and health providers to identify health inequalities and priorities, it gives everyone the opportunity to work collaboratively to tackle the issues that arise. It’s a meeting place for people to come together and talk about what matters most. The Forums offer a way of working together to make a difference. It’s great to be involved in a process that gives local people a say in how services are provided in the neighbourhood. I enjoy working with different groups and organisations to see things differently and to try to come up with local solutions to making services work better.

What does the facilitator role involve for you? What does a typical day look like?

The job is different every day, I am forever chatting with different individuals and groups on a huge range of issues. People will be ringing asking for example – what’s the best place to hold a meeting, can we use this venue, where can we get funding for our project? Which community organisation can tell us about digital inclusion? – it’s a bit of a switchboard role! I connect with people beyond the forum who have heard about what we do and want to know more. I also do a lot of outreach work to engage people and encourage them to get involved. Then there is the practical planning and sharing of information. I’m involved in supporting three community lunches each week and these are a great chance to find out what’s happening and talk about issues coming up at the Forum. My role on Neighbourhoods and at Wick Aware overlap and compliment each other very well. I’m always building on my community connections. The role is a real mix of hands on delivery and a lot of talking!

How long have you worked at Wick Award and what do you enjoy about it?

I’ve worked for Wick Award for 8 years now. I have lived in Hackney since 1988 and live with my partner and my daughter who’s 14. I’d previously worked in community development in a range of roles and was interested in the approach of Big Locals, so the role really appealed to me as well as suiting my personal situation having a young child at the time.

Who else do you work with in your neighbourhoods?

Everyone! Faith groups, youth groups, community organisations, tenants, GP practices and resident groups.

Workwise, what motivates you to get out of bed in the morning?

It’s a chance to listen to people get things done differently, working with people to make change and influence services making them more responsive to residents. I want to support people to share their experiences and ideas and have a real say in their neighbourhoods.

How do you know your work has been successful – what are your favourite examples?

It’s lovely to hear individual stories, where people have been able to get what they need, share their skills, and have real input that makes a difference to their lives as well as lives of other local people.

I love it when people get back to me after a Forum meeting to say ….”I’ve been thinking and I reckon that this will work in Well Street Common- let’s see what other people think”. A resident who has attended Well Street Common Forum was introduced to community activities by a neighbour with contacts and now she wants to share her ideas for helping local carers get involved in a walking group.

When we recruited a sixteen year old Hackney Wick girl to support our community research, we knew that she was super-bright and really passionate about making changes for young people in Hackney Wick. We were delighted when her Dad decided to get involved and joined the Wick Award Partnership Board. Now that girl has a great career in the civil service and is leading on projects that will have big impacts on a national level. We are very proud to have worked with her at the beginning of her career path.

What do you love about Hackney?

Hackney has been my home since 1988, I didn’t start out here but I want to stay. I love the buzz and amazing range of stuff going on. This week someone told me about the Hackney Colliery Band – now that’s amazing! So much great music. I love that my daughter has grown up here, having the chance to play with the Borough Youth Orchestra. There is a corner of Hackney for everyone. It has been brilliant to live and work in this great community. I am never surprised when you find out that a Hackney person is behind some great new idea.