Neighbourhood Health in Practice: What Happens When Primary Care Leaves the Building

The backstory: where the idea came from

The idea didn’t start at the Mela.

It started, as many things in general practice do, in a partners’ meeting after a long clinical day. We were talking about the same frustrations we’d been circling for years. We knew who our highest-risk patients were. We knew which communities carried the greatest burden of cardiovascular disease, diabetes, and hypertension and yet we were still largely waiting for people to come to us.

The NHS 10-Year Plan talks clearly about neighbourhood health, prevention, and reducing inequalities

What does neighbourhood health look like on the ground?

We had already experimented with taking care into the community. We had run outreach work in libraries and on high streets, voluntarily, alongside core practice work. Those experiences taught us two things. First, people would engage when services felt accessible and familiar. Second, trust mattered more than messaging.

The Middlesbrough Mela felt like a natural next step.

What is the Mela, and why choose it?

The Middlesbrough Mela is a large, well-established cultural festival, rooted in the South Asian community and attended by thousands of families over a weekend. It is not a health event. People come to eat, celebrate, socialise, and spend time with their children.

That was precisely the point.

South Asian communities are at higher risk of cardiovascular disease and type 2 diabetes, often at younger ages, yet uptake of routine NHS Health Checks remains variable. Barriers are well described: language, time, trust, competing priorities, and sometimes fear of medical settings.

By choosing the Mela, we weren’t trying to “pull” people into healthcare, we were deliberately placing healthcare into a space that already felt safe, familiar, and enjoyable.

This approach is not without precedent. Pop-up health screening in non-clinical settings has been shown to reach people who do not routinely engage with healthcare, including a UK shopping-centre blood pressure screening study.

Healthy shopper? Blood pressure testing in a shopping centre Pop-Up in England - PMC

What is less well explored is how primary care teams themselves can lead and operationalise this work at neighbourhood level.

The decision: what we wanted to achieve

The partners agreed three clear aims:

1. Early detection of long-term conditions in a high-risk population
2. Access by removing the need for appointments, buildings, and familiarity with the system
3. Trust by delivering care through people who understood the community

We were also clear about what this was not. It was not a pilot funded by an innovation pot. It was not a research project. It was a deliberate decision by a practice to absorb the cost and organisational burden because we believed this was core general practice work.

Elm Tree Medical Centre led the initiative, coordinated partners, and provided most staff. The total cost to the practice was around £8,000–£10,000.

Operationalising neighbourhood health

Neighbourhood health can sound abstract. In practice, it required very concrete decisions.

Over two days at the Mela, we assembled a team of 20 staff, including GPs, nurse practitioners, paramedics, reception and admin staff, POCDOC, Health innovation North East and North Cumbria (HINENC) representatives, and Middlesbrough FC (football club) staff. Importantly, many of our clinicians and support staff were from South Asian backgrounds, which fundamentally shaped how conversations happened.

The model was simple:

People walking past could stop voluntarily. Consent was taken verbally and in writing. Over the course of approximately 20 minutes participants received blood pressure checks, BMI assessment, finger-prick lipid testing, HbA1c testing, QRISK3 calculation, and personalised lifestyle advice. Results were discussed immediately, face-to-face, with a GP signposting any follow up maybe required.

Children’s games, activities, and free items were deliberately placed alongside the stand. This was healthcare embedded in everyday life, not separated from it.

What we found

A total of 165 people completed full assessments.

The data confirmed what population statistics already suggest, but made it tangible:

• 65% of people were overweight OR obese
• A substantial number (35%) with raised blood pressure requiring follow-up
• Moderate to high cardiovascular risk in a significant minority (20%)
• Raised HbA1c levels in people who often did not realise they were at risk

Based on clinical judgement, around 10% of abnormal results represented likely new diagnoses. Most participants were not registered with our practice, and many had not engaged with primary care for some time.

Almost everyone received lifestyle advice. For some, this was the first time a clinician had sat with them and explained cardiovascular risk in plain language.

Strengths of this approach

Several strengths became clear.

First, collaboration. This work was only possible because of partnership. Middlesbrough FC provided legitimacy and footfall. HINENC supported communication and trust. POCDOC enabled rapid point-of-care testing. Elm Tree Medical Centre brought clinical governance and primary care expertise).

Second, reach. We spoke to people who would not have attended a surgery. The setting mattered as much as the service.

Third, trust and culture. Language concordance and cultural familiarity changed the tone of interactions. Conversations were calmer, longer, and more open.

Finally, credibility. During the event, a senior NHS leader visited the stand, spent time with the team, asked detailed questions, and explicitly raised the possibility of replication elsewhere. That moment reinforced that this was not simply “nice work”, but something system leaders were actively looking for.

Limitations and challenges

This work was not easy.

It required significant coordination, senior clinical presence, and staff goodwill. It is difficult to do alone. The cost, around £10,000, is not trivial for a practice to absorb repeatedly. Data interoperability was limited, meaning results could not automatically flow into NHS primary care records.

There is also the question of follow-through. Awareness is valuable, but what matters is what happens next.

Discussion: what does the public do with the data?

One of the most important questions raised by this work is what happens after someone learns they have raised cholesterol, high blood pressure, or increased cardiovascular risk.

On the day, GPs explained results clearly and provided guidance on next steps. Patients that were already registered with our practice could be supported directly. Others were advised to contact their own GP appropriately.

Information alone is not enough. Some people feel reassured and motivated. Others feel anxious. Some act immediately. Others do nothing. This variation matters.

As healthcare increasingly generates data outside traditional settings, interpretation becomes as important as measurement.

What next?

The Mela organisers have invited us back, offering a more central location based on feedback. Our intention is to return with a larger team, greater testing capacity, and improved preparation.

To scale this work, we will need:

• Dedicated funding
• Better coordination at ICB and national level
• Improved data integration
• Clear clinical pathways for follow-up

This is not work that should rely on goodwill alone.

Final reflection

Neighbourhood health is not a concept. It is a set of choices. It’s choosing to step outside the building, to work in partnership, not silos. The aim is to focus on prevention, not crisis response and to meet people where they already are.

The Middlesbrough Mela showed that when primary care leads, neighbourhood health is not only possible but welcomed. The challenge now is to move from isolated examples to sustained, supported delivery at scale.

Continue the conversation at the HETT Leaders’ Summit

The questions raised by this work are not unique to one practice or one community. How neighbourhood health is funded, led, operationalised and sustained is now a live challenge across the system.

These are exactly the kinds of practical, experience-led discussions taking place at the HETT Leaders’ Summit, bringing together people involved in digital, clinical, operational and data strategy from across health and care.

The Summit provides space to share what has worked, what has been difficult, and what needs to change if neighbourhood-based prevention is to move from isolated examples to system-wide delivery.

The HETT Leaders’ Summit takes place on Thursday 12 February 2026 at the Royal Armouries, Leeds. It is free to attend for NHS, public sector, academic and not-for-profit organisations, fully catered, includes a networking drinks reception, and offers CPD points.

If you are grappling with how neighbourhood health can work in practice, we would welcome you to join the conversation.