Rotherham has a population of approximately 270,000 and experiences diverse health needs and demographics; a high prevalence of long-term conditions and disabilities; and deep-rooted health inequalities.  Partners in health, care, the local authority and the voluntary sector are collaborating to develop a programme of work designed to strengthen existing neighbourhood working rather than create new structures. This will focus on three priority areas Prevention, Rising Risk, and Complex Frailty, each led by an Executive SRO to ensure governance, pace and system leadership.  

The Prevention work focuses on increasing uptake of Over40s Health Checks, particularly in more deprived neighbourhoods where longterm conditions develop earlier and often go undiagnosed. By redesigning delivery with communities and improving pathways into support, Rotherham aims to boost early identification and reduce future demand on services. 

The Rising Risk work targets 18-39 year olds with one physical longterm condition and depression. This group is at high risk of rapid deterioration. The neighbourhood model will test earlier identification through risk stratification, enhanced proactive care and integrated physical and mental health support to build resilience and reduce escalation. 

The Complex Frailty work focuses on residents with multiple longterm conditions and recent hospital admissions. The programme aims to improve care planning, reduce duplication, and embed coordinated multidisciplinary neighbourhood approaches. While full impact requires longterm work, foundations will be laid during the remaining period of the NNHIP programme.