Case Studies
Project Brief:
Establishing a Neighbourhood-Ready Wellbeing Hub for a PCN in Wandsworth
The project brief was to provide a specialist Neighbourhood Health Worker (a SPLW funded under the ARRS) to establish a Neighbourhood-ready Community Wellbeing Hub, a model that would allow the PCN to pilot proactive, population-based care ahead of full Neighbourhood rollout.
The hub needed to be flexible, dynamic, and locally tailored, aligning with Neighbourhood priorities such as prevention, inequalities, frailty and mental health. By embedding the principles of data-led decision-making, partnership engagement, and community activation, the project demonstrated how the upcoming Neighbourhood model could really work in practice.
Why
Understanding Local Need and Targeting the Right Populations
Using Population Health Management data, local insights and frontline intelligence, several Neighbourhood-appropriate patient cohorts were identified who would most benefit from proactive, community-based interventions:
- Individuals with hypertension and cardiovascular risk (Core20PLUS5 focus area)
- Carers and socially isolated residents, who often fall between services
- People with multiple long-term conditions and frailty, needing early intervention to avoid escalation
- Residents in deprived areas with limited access to preventive care or wellbeing activities
What We Did:
Building and Managing the Wellbeing Hub
Working collaboratively with the PCN, our Neighbourhood Health Worker identified and secured a community space free of charge to operate as the PCN/Neighbourhood Wellbeing Hub. The NHW then coordinated partners, promoted the service through local practices, and led on organising and delivering programmes targeting the identified population cohorts.
The Wellbeing Hub delivered:
- “Know Your Numbers” health checks – blood pressure and health screening sessions, targeting populations with low activity, aligned with Core20PLUS5 (CVD prevention priority).
- Carers’ Events – a session connecting carers with local support, information and respite opportunities.
- Coffee & Chat mornings – reducing isolation and building community connection among older and vulnerable patients.
- Walk & Talk sessions – gentle, social activity promoting physical and mental wellbeing.
- Physiotherapy Group Sessions – organised by the NHW and delivered by the PCN’s First Contact Practitioner (FCP), targeting local patients with MSK conditions, frailty, and reduced mobility, identified through practice data and aligned with Neighbourhood priorities around healthy ageing, prevention, and physical activity.
- Sessions focused on strength, balance, mobility, and pain education.
- Patients were encouraged to self-manage, stay active, and engage in ongoing community exercise options, with the aim of reducing FCP/GP follow-ups and unnecessary MSK referrals.
- Breast Cancer and Menopause Awareness workshops – targeted health education addressing screening uptake and gender-specific health inequalities.
- Health Promotion & Prevention sessions – thematic talks on nutrition, sleep, exercise and managing long-term conditions delivered in collaboration with PCN GP.
- Each initiative was designed to address key Neighbourhood and ICS priorities: prevention, early intervention, mental wellbeing, and reducing health inequalities.
- The Wellbeing Hub’s flexible delivery model allowed the PCN to activate existing ARRS workforce, partner with voluntary organisations, and test a scalable approach for the future Neighbourhood framework. The Wellbeing Hub is still being delivered.
Impact, Outcomes & Learning
- 27 Wellbeing Hub sessions delivered across the pilot period
- 244 patient attendees, representing a broad mix of ages, backgrounds, and health needs
- BP checks identified untreated hypertension and led to proactive GP follow-up?
- Positive feedback from carers and patients about accessibility and atmosphere.
- Improved multi-stakeholder relationships - regular communication between SPLWs, practices and voluntary partners.
- Established a replicable blueprint for future Neighbourhood Wellbeing Hubs across the borough.
- Regular attendance has promoted preventive health behaviours, peer-to-peer support, and self-management of long-term conditions, reducing avoidable reliance on GPs by attending the Wellbeing Hub.
- 85% of patient attendees reported feeling “much better” since attending, highlighting a significant positive impact on mental health and wellbeing
- Participants also reported feeling:
- More connected and less isolated
- Better informed about local services and resources
- More confident managing their own health and wellbeing
- Noticeable increase in appropriate referrals to local community and voluntary sector services
Summary
The PCN Wellbeing Hub has proven that even a small, well-coordinated Neighbourhood initiative can deliver meaningful health improvements, community connections, and measurable system benefits, providing a clear blueprint for future Neighbourhood-based models with actual delivery right now.
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