The tech for neighbourhood care is here – now it’s time to scale

We need to scale neighbourhood care to make it the default model of delivery, writes Laura Thompson, director, health and government, at The Access Group

With 7.4 million people currently on NHS waiting lists, the case for shifting towards prevention, community-based care, and digital innovation is stronger than ever.

The government’s 10 year health plan highlights these strategic priorities, but the real question, at least in the short term, should be how to scale the examples that are already working across our neighbourhoods.

Plus, with research by the University of Wisconsin Population Health Institute, showing that clinical care contributes only around 20% to overall health outcomes compared to social and economic factors accounting for c50%, for the long-term national plan to succeed, we need to look beyond hospitals and GP surgeries and address the wider determinants of health.

Proven impact 

For example, Sutton Council uses AI-powered sensors to detect subtle changes in daily living patterns, from reduced mobility to changes in eating habits, allowing early intervention for risks such as falls, malnutrition, or infections, before they escalate.

Data from Sutton’s evidence base found that in 2024 the service diverted an average of 55 referrals a month away from emergency services and towards NHS two-hour urgent community response teams.

Similarly, a Community Interest Company in Wales – Warm Wales – has addressed fuel poverty through energy advice, home improvements, and income maximisation and generated both financial and health benefits.

One participant reported “being able to heat the house for longer eased my depression” and benefits analysis shows that 74% of recipients reported reduced anxiety. Which, no doubt, has also had a positive knock-on effect on the number of trips to the GP surgery.

These examples show that neighbourhood care – that tackles all determinants of health and wellbeing – is not an abstract concept but a working reality that is already reshaping the way services are delivered.

Digital infrastructure

The technology to support neighbourhood care in this context already exists, but its success depends on how it is implemented. Too often, we find that digital transformation has meant introducing new systems that add administrative burden or create new silos.

When we should be thinking about intelligent integration – using interoperable platforms and Fast Healthcare Interoperability Resources (FHIR) standards to connect what is already there.

Shropshire Community Health Trust and Midlands Partnership University Foundation Trust provide great examples. Rather than replacing existing systems, they have introduced an intelligent platform layer that connects multiple clinical systems. This provides real-time alerts and highlights care gaps without requiring wholesale change.

As Shropshire’s chief information officer, Jonathan Davies puts it: “It’s about making the right information available to the right people, at the right time, and in the right place.”

For cash-constrained systems, this principle of continuity rather than replacement can make all the difference.

Reality check

However, we all know it’s easier said than done.

The reality is that the shift to neighbourhood care can initially add pressure to already-stretched services in primary care, mental health, and social care.

To manage this, systems need to rethink commissioning models and service design. Outcome-based commissioning, for example, measures population health improvements rather than simply counting interventions. When prevention outcomes are funded directly, investment naturally flows to local, community-level interventions.

Equally, social infrastructure – community centres, local support networks, voluntary organisations – needs to be treated as essential healthcare infrastructure, not optional extras. A community hall that reduces isolation or a local support network that prevents relapse may do more for health outcomes than an additional clinic.

And while the 10 year health plan’s emphasis on prevention and community-based services creates a clear policy window, it won’t deliver change alone.

Leadership is needed across every level of the system. We need commissioners who are willing to fund outcomes rather than activities. We need technologists who integrate systems rather than creating new silos. And we need to recognise the value of a housing officer preventing cold-related illness just as much as a clinician treating its consequences.

Looking ahead 

We know that there are proven examples already out there. And the technology exists. Plus, the policy direction is supportive.

What is needed now is the collective will to scale up neighbourhood care and make it the default model of health and care delivery.

Based on our experience of working with more than 45 NHS trusts and 200 local authorities, three practical steps stand out for leaders looking to accelerate this shift:

• Optimise existing tools before investing in new systems.
• Focus on populations with complex needs, where proactive care can prevent crises and avoid admissions.
• Invest in digital overlays that connect, rather than replace, existing infrastructure.

The future of healthcare isn’t in our hospitals – it’s in our neighbourhoods. That future is being built today by communities that understand prevention. Addressing root causes will always be more cost-effective than treating resulting conditions.

The question for all of us is: are we ready to lead this transformation?

The Access Group, a provider of digital care software for health, social care, education, and youth services, is co-headline sponsor for Digital Health Rewired 2025 and will also sponsor the Integrated Care Stage.