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Stage 3: Actively connect people to the right intervention or support
Bridging the gap between identification and impact
For local authorities implementing targeted proactive prevention, successfully identifying individuals at risk and understanding their needs represents only part of the challenge. The critical next stage involves effectively connecting people with the right combination of support to address their specific circumstances and build resilience.
This connective function transforms theoretical prevention opportunities into practical impact. Without careful attention to this stage, even the most sophisticated identification systems and comprehensive assessments will fail to deliver meaningful outcomes for individuals or measurable benefits for systems.
On this page you can find out:
- the steps involved in this stage
- case studies from local authorities already doing this in practice
- implications for evidencing prevention
- potential barriers you might face and how to overcome these
The most effective prevention models approach this connection process through three interconnected steps:
Step 1: Understanding available support
Successful authorities develop comprehensive knowledge of available support options across statutory services, VCFSE organisations, and community assets. This mapping creates the foundation for personalised support planning, enabling practitioners to draw upon the full spectrum of local resources rather than defaulting to a limited menu of standard services.
Resource mapping approaches:
Develop unparalleled knowledge of local provision through direct engagement with service providers and community groups. These roles—variously titled as social prescribers, link workers, or community navigators—become repositories of valuable information about eligibility criteria, capacity, and practical access details that might not appear in formal directories.
The effectiveness of these roles depends on continuous professional development and protected time for relationship building with local organisations. One authority found that connectors who spent at least 20% of their time maintaining provider relationships achieved 30% higher successful referral rates than those who focused exclusively on client interactions.
Consolidate information about available support into searchable resources for both practitioners and residents. The most valuable directories include practical details beyond basic service descriptions—such as current waiting times, accessibility features, and transport links—that influence whether someone can meaningfully engage with support.
Regular updating mechanisms are essential for maintaining directory relevance. The Wokingham Joy App, for example, implemented a quarterly verification process for all listed services, resulting in 92% accuracy of information compared to 68% in their previous static directory.
Visualise service availability across local areas, identifying coverage gaps and revealing opportunities for more equitable provision. Authorities using geographical information systems can overlay service locations with demographic data, transport routes, and deprivation indices to understand practical accessibility beyond simple distances.
The Wokingham Integrated Partnership introduced Joy, a social prescription app that connects individuals to over 130 local services, improving access to support and reducing reliance on statutory care. Used by GPs, social workers, hospitals, police, and community navigators, the app helps professionals refer people to health and wellbeing services, social activities, and practical support quickly and efficiently.
How It Works
The JOY Marketplace allows residents and professionals to find local health and wellbeing services that meet their needs before making referrals.
Users praise the app for being intuitive and easy to use, offering a single, comprehensive platform that improves responsiveness to local needs through detailed data and real-time feedback.
Impact
- 23% decrease in GP appointments, reducing demand on primary care.
- 71% of users reported improved wellbeing.
- More efficient care coordination and service delivery.
What’s Next?
Wokingham aims to further embed Joy into health and social care services, expanding its reach to enhance preventative support, strengthen integrated care partnerships, and improve data-driven decision-making.
Step 2: Matching individuals to the right support
With a comprehensive understanding of both individual needs and available resources, authorities focus on creating personalised connections that maximise the likelihood of successful engagement and positive outcomes.
Principles for Effective Matching
Authorities consider the individual’s strengths, cultural background, and aspirations to create empowering support and independence plans that go beyond addressing deficits.
Accessible, transparent information about available options helps individuals make informed decisions, enhancing their engagement and confidence.
Locally rooted services often offer greater flexibility, allowing individuals to stay connected to their communities while addressing their needs.
Methods for Matching
Teams from various sectors collaborate to create comprehensive, tailored solutions for individuals in complex situations.
Practitioners work closely with individuals to co-design support plans, fostering trust and ensuring alignment with personal goals (see for example the Outcomes and Support Sequence case study from Leicester City Council).
The most suitable matching method often hinges on the complexity of individual needs and circumstances, the availability of multidisciplinary expertise, and the individual’s preference for involvement in decision-making.
The South West London Integrated Partnership is transforming care through Multi-Disciplinary Teams (MDTs) as part of the Proactive Anticipatory Care (PAC) Model. This approach enables health and social care professionals to work together to deliver coordinated, proactive support that helps residents stay healthier for longer and reduces the need for reactive care.
Each person’s care is discussed in a weekly MDT meeting, which includes GPs, community nurses, social care teams, and hospital specialists. The team collaboratively develops personalised care plans, addressing both health and social needs, and suggests support and interventions to meet a person’s specific needs and goals. This ensures residents receive timely support and can remain in control of their care decisions.
The PAC model also tackles the wider determinants of health, helping residents engage with their community and stay socially connected.
Step 3: Actively connecting individuals to support
Even when appropriate support is identified, practical, psychological and financial barriers can prevent successful engagement. The most effective prevention models include proactive facilitation to address these barriers, recognising that connection is a process rather than a single event.
Engagement facilitation approaches
Addresses logistical obstacles that might otherwise prevent access to support. These include transport challenges, scheduling conflicts, digital access issues, or financial constraints.
Successful authorities develop systematic approaches to identifying and addressing common barriers. For example, one council established a prevention enablement fund that provided small grants for transport costs, digital devices, or complementary expenses that would otherwise prevent engagement with preventative support. Personal budgets are another approach whereby these are used to pay for transport or preferred support options.
Helps individuals overcome anxiety, stigma, or low confidence that might limit engagement. Techniques such as motivational interviewing, peer support, and graduated exposure help build the psychological readiness needed for successful participation.
Several authorities have developed peer mentor programmes where individuals who have previously benefited from preventative support accompany new referrals to initial sessions, substantially reducing non-attendance rates for services addressing social isolation or physical activity.
Remove procedural barriers to service access. "No wrong door" approaches ensure that regardless of where someone first makes contact with the system, they can access appropriate support without navigating complex referral processes or repeating their story multiple times.
Sustained engagement requires consistent follow-up and adaptation to changing needs. Key workers or Local Area Coordinators can play a vital role in maintaining regular check-ins, providing support, and ensuring interventions remain effective. This ongoing connection helps individuals feel supported and ensures that services continue to align with their evolving circumstances.
The decision on how to facilitate access and engagement should be informed by the most common barriers in the community, such as logistical issues or emotional resistance, and the local authority’s capacity to provide targeted support.
Birmingham’s ICS has developed its model for integrated neighbourhood teams (INTs) with a vision for people to live longer, healthier, happier and more independent lives – and prevention is core to this vision.
The team first identified individuals with a range of complex health and care needs who were frequently accessing a wide range of services, to ensure they could support them at the right time with the right intervention, improving outcomes for this group while simultaneously avoiding unnecessary hospital attendance and admissions and development of greater care needs.
A multi-disciplinary group of staff across system partners reviewed these individuals and identified four key interventions that were relevant in 80% of cases: structured medication reviews, community mental health support, short-term services such as reablement, and social prescribing.
In designing and setting up the pilot INTs, Birmingham ensured that representatives from these services were included as core members of the INT, and simplified referral routes to allow for a direct referral via email from any member of the INT to increase the likelihood of successful connection to these interventions.
Scaled up, there is an opportunity for INTs to support 20,000 frequent system service users, preventing at least 15 per cent of the 850,000 contacts they have with health and care services every year.
While the work is still at a relatively early stage, results from the two pilot PCNs in east and west Birmingham are already showing a significant stabilisation in service use for individuals who are receiving an INT intervention.
Findings range from a reduction of 32 per cent in primary care appointments through to a 15 per cent reduction in ED attendances, as well as fewer inpatient spells and bed days, outpatient services and community contacts.
Oxfordshire started implementing integrated neighbourhood teams (INTs) in 2023. The county now has four INTs focussing on frailty, three of which are in areas of significant deprivation. In these areas, with the local council and volunteer groups, system partners have worked with each community to establish how they can make health care more accessible and improve their quality of life and life expectancy.
The approach began with a small number of staff in the INTs who carried out various educational sessions in the local community centres, focussing on clinical conditions. This brought a variety of people together where other healthcare professionals were present. The additional focus was on what they needed from healthcare. Areas were identified for improvement, such having access to diagnostic tests closer to home, supporting people to complete forms to improve the environment in their house (social housing) and general citizens advice.
Oxfordshire County Council ran webinars with healthcare professionals working within these areas of significant deprivation, to explain how they can refer appropriate people on to the various council teams. This led to a more integrated working across local communities, local council and healthcare.
As a result, Oxfordshire now has INT services working with local councils and communities to build on these connections and focus on what is important to individuals. They have had examples of people going from living in houses where healthcare staff cannot get beyond the front door to staff working with these people to ascertain how we can better support their needs.
On the day multi-disciplinary teams calls were established to discuss individuals who require urgent support to remain in their own home. This has resulted in one person with significant hoarding receiving care whilst maintaining his trust. Another person was maintained safely in their own home despite a family member developing a psychosis and not allowing any carers to deliver the care their mother required. Prior to this, an ambulance would have been called and they would have been inappropriately transferred to hospital.
Barriers and mitigations to implementing this stage of the delivery model
Incomplete or Outdated Knowledge of Local Support Resources
- Challenge: Local authorities may face challenges in maintaining an up-to-date, comprehensive map of available resources, leading to gaps in service delivery and delays in connecting individuals to appropriate support.
- Mitigation: authorities overcoming this issue regularly update community directories, invest in AI-powered mapping tools like Copilot and ESRI, and rely on community connectors (such as Local Area Coordinators) and social prescribers to maintain a current knowledge of available services. Collaboration with service providers ensures that resource information is accurate and actionable.
Limited Capacity of Local Services
- Challenge: Local services, including statutory, VCFSE and support provider organisations, may face resource constraints, making it difficult to meet the growing demand for support, particularly when multiple individuals require tailored services simultaneously. This can result in delays or reduced quality of support.
- Mitigation: authorities overcoming this challenge strengthen partnerships with VCFSE and support provider organisations to increase service capacity and flexibility. They identify and address service gaps through proactive mapping and engage in resource-sharing agreements. They explore alternative delivery models such as peer support, community-led initiatives, or digital platforms to supplement traditional services. Additionally, they align capacity planning with predicted demand to ensure adequate resources are available, and prioritise services based on the most critical needs and build in flexibility for high-demand periods.
Limited Access to Community-Based Services
- Challenge: Some individuals may face challenges in accessing locally based support due to a lack of flexible services or limited capacity within community organisations.
- Mitigation: authorities overcoming this issue prioritise community-based services that offer flexibility and greater integration with individuals’ local contexts. They build stronger connections with voluntary, community, faith, and social enterprise (VCFSE) organisations to enhance the capacity of local resources and ensure individuals can remain connected to their communities.
Practical and Emotional Barriers to Service Access
- Challenge: Even if the right support is identified, individuals may face practical barriers (e.g., transportation, cost, language) or emotional barriers (e.g., fear of stigma, anxiety) that prevent them from accessing services.
- Mitigation: authorities overcoming this challenge address logistical issues by providing solutions like discounted transport, translation services, or community-based support. They create peer support programs to reduce emotional resistance and build trust, especially for individuals who may fear stigma. Implement "no wrong door" policies to make accessing services easier, offering multiple entry points for engagement.
By addressing these barriers, local authorities can effectively connect individuals to tailored, community-based support and ensure that services are accessible and impactful, leading to better outcomes and sustainable prevention.
Implications of this stage for evidencing prevention
By focusing on the connection process, authorities can gather practical data on both the direct impact of interventions and the overall effectiveness of their prevention strategies. This stage provides valuable insights into how tailored support systems lead to improved outcomes.
- Outcome tracking: Collect data on key short-term improvements, such as increased engagement and uptake of services, and/or better well-being. Common evidence might include service usage reports, survey results on individual progress (e.g., reduced isolation), and feedback from service providers.
- Barriers to engagement: Track and assess barriers—logistical, emotional, or social—that hinder access to services. Data could come from client feedback, service access reports, or case studies identifying common challenges. This helps authorities adjust strategies for broader accessibility.
Summary of key points
- Leverage comprehensive support networks: Utilise the full spectrum of local resources, including VCFSE organisations and statutory services, to tailor interventions that address individual needs and promote well-being.
- Treat holistic conversations as interventions: Use conversations not only to identify risks and goals but as a means of empowering individuals, building their confidence, resilience, and ability to engage with support services.
- Map and understand available support: Develop a thorough understanding of local services and their capacity to meet diverse needs, employing strategies like community connectors, comprehensive service directories, and real-time data sharing.
- Prioritise matching and connecting to the right support: Adopt a person-centred approach to match individuals to the right services, addressing barriers to engagement and providing ongoing support to ensure access and sustained service usage.
