Delivery Model - Stage Two

This stage recognises that effective prevention requires understanding not just what challenges a person faces, but what matters to them, what capabilities they possess, and what barriers might prevent engagement with support, so that the most suitable preventative support can be offered.

Two senior women smiling and walking together on a city street

For authorities implementing targeted proactive prevention, identifying at-risk individuals is only the beginning. The second critical stage involves building authentic relationships and developing a comprehensive understanding of each person's unique circumstances, strengths, and aspirations.

This holistic approach represents a fundamental shift from traditional assessment processes that often focus narrowly on deficits. Instead, it recognises that effective prevention requires understanding not just what challenges a person faces, but what matters to them, what capabilities they possess, and what barriers might prevent engagement with support.

useful information

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

This stage comprises two key steps that transform initial identification into meaningful engagement:

Step 1: Initial proactive outreach

The first engagement with individuals sets the tone for the entire prevention journey. Thoughtfully designed outreach establishes trust and credibility, particularly important when approaching people who have not sought services themselves and may have limited or negative previous experiences with formal support systems.

Key elements of effective outreach:

Leveraging trusted relationships

Significantly enhances engagement rates. Authorities find that initial contact through professionals with existing rapport—such as GPs, social workers, homecare workers, or community leaders - establishes immediate legitimacy and reduces barriers to engagement.

For example, one authority found that letters from GPs about falls prevention achieved a 38% response rate compared to just 12% when sent directly from the council, despite identical content. Similarly, when community pharmacists introduced a medication review service during prescription collections, uptake increased threefold compared to postal invitations.

Adapting communication methods

Ensures accessibility for diverse cohorts. This includes addressing practical barriers like digital exclusion, language needs, or sensory impairments, as well as psychological factors such as anxiety about engagement with formal services.

Most successful authorities employ multiple communication channels tailored to individual preferences, ranging from traditional written correspondence for older cohorts to text messaging for more digitally engaged groups. Materials in community languages, easy-read formats, and visual communication options ensure inclusivity.

Aligning with context and timing

Improves receptiveness to preventative offers. Embedding outreach into existing touchpoints—such as annual health checks, community hub visits, or pharmacy interactions—reduces barriers while reinforcing the legitimacy of the approach.

The most effective timing often follows predictable life transitions when people may be more receptive to preventative support, such as after hospital discharge, following bereavement, or upon retirement.

Step 2: Building a holistic understanding

Once initial engagement is established, the focus shifts to developing a comprehensive understanding of the person's circumstances, strengths, and goals. This investment in understanding pays dividends by ensuring subsequent interventions are personalised, meaningful, and aligned with individual priorities.

Approaches to building holistic understanding:

Multi-disciplinary collaboration

Brings together insights from across health, social care, and community services to create a complete picture of both challenges and strengths. This prevents fragmented assessments that might miss important connections between different aspects of a person's life.

For complex situations, multi-disciplinary team reviews can be particularly valuable. One authority found that combined assessments between occupational therapists, social workers, and housing officers identified 40% more environmental risk factors and twice as many potential community-based solutions compared to single-discipline assessments.

Co-produced goal setting

Engages individuals in defining what matters most to them, establishing Specific, Measurable, Achievable, Relevant, and Time-bound (SMART) goals that reflect personal priorities rather than service-defined outcomes.

Effective goal-setting discussions often use coaching techniques and visual tools to explore aspirations beyond immediate needs. For example, some authorities use wellbeing wheels or picture cards to facilitate conversations about priorities with people who might find abstract discussions challenging.

Practitioner-led empowerment

Helps individuals navigate available support with confidence. Skilled practitioners use strengths-based conversations to explore not just what someone needs, but what capabilities and networks they already have that can be built upon.

These approaches are adapted based on individual circumstances:

For people with complex needs, dedicated time and potentially multiple conversations may be needed to build trust and develop a full understanding
For those experiencing crisis, focusing first on immediate concerns while gradually building towards longer-term preventative goals often proves most effective
For individuals with well-defined goals, structured single-session approaches in comfortable settings like community hubs can enable rapid progression to action planning

Barriers and mitigations to implementing this stage of the delivery model

Lack of Trust and Reluctance to Engage

Challenge: many individuals may hesitate to engage with outreach efforts, particularly if they have had negative past experiences with services or are unfamiliar with prevention programmes.‍
Mitigation: authorities overcoming this issue leverage trusted professionals (e.g., GPs, social workers, carers) to initiate outreach, ensuring communication is led by those with established rapport. Personalised outreach, such as phone calls or letters from familiar sources, can build legitimacy and trust.

Digital Exclusion and Communication Accessibility

Challenge: older adults or individuals from diverse communities may be inaccessible via digital means due to technology limitations or language barriers.‍
Mitigation: authorities overcoming this challenge tailor outreach methods to specific needs, such as using physical letters, phone calls, or community events for outreach. They ensure that communications are accessible by providing translated materials or offering support for digital navigation.

Resource Constraints and Limited Capacity

Challenge: limited staff capacity or funding may restrict the scope of outreach and follow-up efforts, undermining engagement and trust-building.
Mitigation: authorities overcoming this issue focus outreach efforts on existing touchpoints (e.g., GP appointments, community hubs) to integrate proactive engagement into routine services. They prioritise outreach based on available resources while exploring partnerships to increase reach.

Fragmented Data and Lack of Coordination Across Services

Challenge: siloed data across health, social care, and community services may impede a comprehensive understanding of an individual’s needs and strengths.
Mitigation: authorities overcoming this challenge foster multi-disciplinary collaboration to share insights and create a unified view of individuals’ circumstances. Integrated data-sharing agreements and cross-sector partnerships can improve data accessibility and ensure a holistic understanding.

Implications of this stage for evidencing prevention

This stage provides crucial evidence to support prevention efforts:

Baseline Data: Initial outreach and holistic understanding establish a clear baseline of individual needs and risks, creating a foundation for tracking changes. For example, VCFSE organisations often use measures like the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) to quantify shifts in well-being over time.
Intervention Effectiveness: A detailed understanding of individual circumstances enables authorities to evaluate which interventions deliver the greatest impact, highlighting areas for refinement and adaptation, allowing for targeted improvement and iteration of recommended interventions.
Engagement Metrics: Response rates and follow-up success provide practical evidence of outreach effectiveness, helping to optimise strategies such as leveraging trusted relationships or personalised communication.‍
Tracking Goal Progress: Setting and monitoring SMART goals creates a structured way to measure success, offering clear evidence of the impact of prevention efforts.

Smiling man in Replay shirt preparing food in kitchen

Case Study: Outcome and Support Sequence – Leicester City Council

Leicester City Council adopted the Outcomes and Support Sequence to create a stronger, more proactive approach to social care and community support. The aim was to empower people to achieve their desired outcomes while reducing their reliance on statutory services, which was particularly important given the higher-than-average number of people receiving statutory support in Leicester.

The council identified the need to take a different approach to support individuals with complex needs, ensuring they received tailored, strength-based interventions that focused on their goals and community resources, rather than increasing formal care packages. This shift was essential to prevent individuals from becoming overly dependent on statutory services and to build stronger networks around people, fostering independence and resilience.

Leicester’s model embedded the Outcomes and Support Sequence directly into everyday service delivery, providing staff with a clear framework to facilitate conversations about desired outcomes. A tailored training program was provided for all staff, with structured onboarding, coaching, and ongoing support, ensuring the framework became a seamless part of their practice.

The initiative focused on three key areas:

Embedding the framework into everyday practice: Staff were encouraged to use the Outcomes and Support Sequence during assessments, reviews, and planning, which was integrated into their business processes and documentation. This allowed staff to build on previous conversations with individuals, ensuring a holistic approach to their support.
Training and ongoing support: A comprehensive training program, including online awareness sessions and direct coaching for those using the tool, ensured that all staff were confident in applying the Outcomes and Support Sequence. The training emphasized the use of everyday solutions and community networks, empowering staff to consider creative alternatives to formal care.
Measuring outcomes and performance: To track the effectiveness of the initiative, Leicester integrated the framework into their performance reporting and quality assurance processes, enabling the council to measure progress over time. Regular briefings for managers and a dedicated information hub helped staff stay informed about the ongoing impact of the approach. The results of embedding the Outcomes and Support Sequence into Leicester’s practice have been significant:

The results were significant: despite a 20% increase in support requests, the council reduced the number of people requiring statutory services. Growth in working-age adults needing services decreased by 3.5%, older people requiring services decreased by 3.4% and care package growth fell from 22% to 15%.