Unlocking prevention in integrated care systems

Background   

Shifting from treatment to prevention is one of the three major shifts the new government wants to achieve, along with moving to care closer to home and towards digitisation. The Hewitt review and the Darzi report have shown there is substantial agreement on the need for a fundamental shift in the model of health and care, from treating ill health to preventing it in the first place. The Hewitt review made recommendations to support a shift of resource towards prevention, to define and identify preventive services and to incentivise local and national prevention efforts (including through payment mechanisms). The government’s upcoming ten-year health plan provides an opportunity to deliver such changes.

The core spend on health and social care dwarfs new pockets of specific money for preventive initiatives, which is currently around 5 per cent of overall NHS spend. The last Conservative government commissioned John Deanfield to write a report on personalised prevention, which estimated that applying early preventative interventions could achieve a 33 per cent reduction in ill health and unlock a £320 billion rise in GDP over 20 years.

In May 2024 the then Secretary of State for Health and Social Care confirmed that the government will be implementing the Hewitt review recommendation on defining prevention spend to support baselining by identifying and benchmarking health service prevention spending, with NHS England and the Department of Health and Social Care (DHSC) working closely together to develop guidance to help integrated care boards (ICBs) with decision-making. But government officials estimate that developing an initial definition and applying this for benchmarking will take several years. Simultaneously, the Chartered Institute of Public Finance and Accountancy (CIPFA) and the Health Foundation are attempting to define and categorise prevention spend within local government over two years.

In the lead up to the general election, various organisations in the healthcare space, including the NHS Confederation, developed ‘manifestos’ to influence a new government. Many of these included a focus on upstreaming and preventing ill health either as a core recommendation or as an overarching theme.

Labour’s manifesto pledged a greater focus on avoidable ill-health prevention throughout the healthcare system and action on improving the health of the public ranging from multiple long-term conditions to banning advertising of junk food to children. Since the general election in July 2024, the new government has provided more detail on its national health mission. An early announcement was that DHSC will lead a ten-year health plan, which must ensure that the shift to a preventative healthcare system is a central tenet for improving population health outcomes. The Darzi investigation into the state of the NHS laid the groundwork for the ten-year plan and underscored the importance of achieving three shifts: from treatment to prevention, hospital to home and analogue to digital.

While there is broad consensus at both system and national level that, if done effectively, prevention will improve health outcomes and make the health and care system sustainable, there is still no national framework such as NHS England's Core20PLUS5 approach to reducing health inequalities. Moreover, this need and commitment offers no guarantee of effective action and there remains a gap between policy statements on prevention and outcomes in practice. Clearly, there are barriers that need to be overcome if we are to unlock the profound benefits offered by a preventative model of healthcare.

To support scalable learning and improvement across the NHS, the NHS Confederation, University of Stirling, University of Southampton and Newton have sought to understand and address barriers to at-scale preventive health and care within ICSs and provide guidance to local leaders. 

The report is based on new research drawing on seven focus group discussions with approximately 60 participants from across 22 ICSs - just over half of all systems in England - with representation from all seven NHS regions. We also spoke to representatives from 19 national organisations, including  voluntary, community and social enterprise (VCSE) organisations, think tanks, national providers, provider representative organisations and central government. See the methodological appendix for more information.

This report establishes: 

• what prevention means to people working within integrated care systems
• the barriers, enablers and opportunities for prevention within systems
• best practice on overcoming those barriers
• the support needed at the national level to progress the prevention agenda through integrated care systems.

These lessons inform a practical guide, developed by Newton, to help leaders learn from others and support systemic change.

The national picture

Integrated care systems (ICSs) were created as formal partnerships in 2022 in recognition of the need to shift the organising principle of the NHS from one of competition to one of collaboration, where the NHS, local government and the VCSE sector work together to deliver improved outcomes to population health and wellbeing at a local level.

At their core, ICSs are partnership collaborators and many of the changes they will bring through new ways of working and commissioning of services will take place over a longer time horizon. Leading system-wide transformation such as the shift to preventative healthcare will take time and sustained commitment from many system partners. ICS leaders want to deliver against their four core purposes:

1. Improving population health and healthcare outcomes. 
2. Enhancing productivity and value for money. 
3. Tacking inequalities in outcomes, experience and access. 
4. Helping the NHS to support broader social and economic development. 

However, in the face of ongoing operational and financial challenges, political attention is driving their focus towards immediate problems of recovering elective and urgent and emergency care and improving primary care access. National policy and guidance does not always provide clarity or incentivise a focus on the prevention agenda. For example, NHS England’s operational planning guidance drives higher focus, resource and capacity on meeting current ‘nationally’ set targets, focused on access and waiting times. 

National targets on prevention do not provide sufficient clarity on outcomes from prevention work, how this links to outcomes frameworks and also the balance between national prescription and local choice. For example, NHS England could provide lists of interventions and activity across primary, secondary and tertiary prevention, with good evidence of cost-effectiveness or equity that local organisations and systems could select based on local need. In terms of long-term physical and mental disease prevention, an acknowledgement of changing disease patterns (epidemiology), ie. increase in multimorbidity, is needed. Given the current single disease management pathways model, this shift to cluster medicine is required to ensure the complex needs of multiple diseases are prevented and managed effectively. 

Despite these challenges, our research has shown that there is a high level of commitment within systems to making the changes needed to drive improvements in population health and to ensure the long-term sustainability of the health and care system, and our research uncovers many examples of progress. ICSs are each on a different improvement trajectory, with some having up to five years head start of partnership working between NHS, local government and other key partners. Differences in demography, geography, politics, local configurations and ways of working call for different approaches and solutions, but there are learnings that can be gleaned from the way local areas and systems have unlocked prevention.

Why prevention is so difficult to secure

Prevention is often presented as the best solution to a social problem, from crime to social exclusion to healthcare. In the name of prevention, post-war UK governments have proposed to change policy and policymaking across the whole of government, to shift resources from the delivery of reactive public services to solve acute problems, to the prevention of those problems before they occur. This transformation could reduce inequalities by focusing on their underlying causes (the social or wider determinants of health), solve the problem of unsustainable public spending, and encourage collaborative policymaking between health and local authorities, stakeholders and communities.

However, the literature shows that post-war UK governments have not known how to take forward this prevention agenda. Research shows cycles of enthusiasm and bursts of initiatives, followed by disenchantment with slow progress and reduced activity when governments move on to other agendas. 

The recurrent message is that health and social care policy makers, both locally and nationally, have tried and failed over several decades to make a shift to a preventative model of care. People agree on the need for prevention, but not what it is or what to do in its name. They agree on the broad need to change but have good reasons to protect current practices and resist challenge. They need, but do not have, the capacity to deliver for the long term. 

This gap between intent and real-world practices can be explained in three broad categories:

Key findings: views from systems leaders 

Defining prevention

With previous research suggesting that the description of prevention is vague, it is important to identify a clear way of thinking about what prevention means and how it ought to manifest in the work of ICSs. One participant described ‘prevention being anodyne’ as the biggest barrier to progressing the agenda. Some prefer to use phrases such as health creation, wider determinants of health, living conditions or building blocks.

While a nationally defined definition will not be able to capture prevention in its broadest sense and local leaders may prefer definitions that reflect the particular needs of their populations, having an agreed understanding of prevention will be crucial to support increases in ICS’s spending on preventative interventions. Without a national definition of what constitutes spending on prevention it will be impossible for ICS partners, local people, MPs, national government and regulators to know whether progress is being made towards shifting funding towards prevention.

In defining prevention, this project detected two distinct ways of thinking: 

A stronger, bolder, more expansive and more transformative view of prevention, sometimes referred to as ‘primary prevention’. As one VCSE representative put it:

"Fundamentally it's that culture and mindset shift, moving from a medicalised model to one that recognises the wider determinants and the social and economic conditions that people live in. That's proving really, really challenging. There's a lot of rhetoric around the 80 per cent of our health that isn't determined by health and care services. But then most of our activity and focus seems to be from the health and care services.” 

In general, this perspective was much more strongly held by those closest to the coalface of prevention work and local communities in practice, especially among general practitioners and place leaders, public health professionals in local government and representatives from the VCSE sector. For these individuals, prevention represents the moral case for state intervention, to foster the public good and challenge the idea that individuals should take sole responsibility for health and promoting a mindset shift towards the social determinants of health. In most focus groups, the phrase ‘left shift’ was used to refer to approaches to prevent ill health in the first place (addressing the wider determinants of health, supporting improvements to health behaviours) and to earlier intervention for those with disease, through better primary, community and social care.

A more cautious, sustainable approach focused on incremental change in a context of extreme financial and operational challenges. As one ICB leader put it:

"I find NHS colleagues can over focus on the need to have an absolute definition of something before we're allowed to move on to the next step of anything... Sometimes that can be the reason for not doing anything. So I think we have to be clear that we don't necessarily have to nail it down so tightly because it'll be all the reasons why you haven't got enough evidence to actually make that that sort of thing happen.” 

Proponents of this view tended more often to be in strategic or system convenor roles and therefore to have a birds-eye-view of the system. They prioritise health-service-focused changes that can demonstrate short-term impact. While these individuals may accept the social determinants framing philosophically, given that they are accountable for overall system performance and therefore convincing politicians to invest in prevention, they may choose a framing that is more politically palatable. They fear that, under the more expansive guise, prevention work can too easily be seen as the ‘holy grail’, or too big a problem to solve. They fear that if, for example, local authorities see prevention as solely their responsibility, it may inhibit rather than bolster collaboration. Instead, then, they favour a focus on achievable aims in relation to specific groups or priorities. They seek to identify interventions that can reduce the burden of disease in the population, to produce results that are societally beneficial and free up healthcare resources by preventing readmissions to emergency care or reducing demand on social care.

Others believe a third way might be opened up between these two extremes, one that centres around ‘split-screen thinking’ (both long-term transformation and incremental immediate action) and that positions tertiary and secondary preventive interventions as a bridge to wider primary prevention over time. 

Overall, these findings demonstrate that simply providing a written definition of prevention does not resolve ambiguity and that, for ICS leaders, there is value in taking the time to establish common aims, language and understandings. 

For the national picture, the findings indicate that a ‘perfect’ definition that is universally accepted will prove impossible to come by. However, there can still be significant value in a framework that gives shape to practice and offers parameters within which individual ICSs can manoeuvre more effectively. A definition and measurement plan would inform the delivery of the government’s ten-year health plan.  

Opportunities and enablers for prevention

Although participants identified many barriers to prevention, they were also hopeful about new opportunities provided by system working, in particular spurred by integrated neighbourhood and place working. When we asked for examples of progress in overcoming these barriers, they identified the successes of early action and provided a wealth of examples of promising or good practice. 

Systems leadership for prevention

One set of promising practices relates to developing effective forms of systems leadership that can cut through some of the administrative barriers to progress on prevention. In the best cases, that leadership starts with a strong strategic vision shared across system partners that is championed by the leadership. For example, we heard a promising account from Nottingham and Nottinghamshire of sustained progress in the face of immense financial and service pressure. Participants described the essential and highly valuable direction and support from ICB senior leaders, able to lead new strategies and provide sustained support for delivery, with prevention being a key pillar in their ICS strategy. There is an impressive will to embed prevention across the system and clear guiding principles that resonate across the system. 

More generally, much focus group discussion identified the need for ‘bravery’ to tackle unsustainable service models and redirect focus towards wellbeing and health creation Ultimately it rests on ICB leaders to increase the amount of money allocated to prevention, joining up with colleagues in local authorities and the VCSE sectors where possible. 

In this context, ICB participants highlighted the potential for a more distributed form of systems leadership that drew on collaborations across its constituent organisations and networks. A particularly promising avenue is to connect to ‘place’ agendas and use the coming together of health and local government devolution as a new opportunity to push for transformative change. For example, North Tyne Combined Authority has capitalised on its devolution deal to better join up existing prevention measures across the system, including by mapping activity. It has also taken the opportunity to push for a radical shared prevention budget between the ICB and combined authority. Early pledges from Labour suggest that this ‘devolution revolution’ is likely to accelerate. 

Leaders often alluded to the notion of the requirement of system leadership and system thinking approaches, where collective action on prevention was required across organisational and professional boundaries grounded in the needs of their communities. It was felt that to maintain the momentum of prioritising prevention it was essential to consider the interplay between system culture and structure, alongside issues of power, uncertainty and trusting relationships.

Embedding collaborative ways of working

Leadership is an important part of the puzzle, but to be successful systems need to find and embed effective ways of integrating services and strategies. Participants described three types of promising collaborative work:

• Combining multiple professional roles in a single service.
• A common aim, shared ethos or reference point.
• Collaborating with community groups.

Several initiatives combine multiple professional roles in a single service, such as to provide housing expertise in NHS trusts, employ mental health nurses in in local authority housing teams, or draw on Citizens Advice in patient mental health wards.

A common aim, shared ethos or reference point can help multiple partners make sense of their collective objectives. This can include shared training and workforce development strategies across teams that enhance may specialist and generalist approaches to prevention.   

Many groups identified visions of the wider ‘communities’ side of prevention, which includes public sector organisations collaborating with community groups. The aim is to value routine or continuous conversations with people you would not normally relate to, and vice versa. For example, continuous professional development should include time to speak directly with communities, and strategic discussions should involve routine and meaningful meetings between service leaders, stakeholders and citizens.

Zooming in allows system leaders to better engage with an area-specific narrative of prevention. An integrated care area with a small population allows for good stakeholder discussion and leadership, and bursts of cooperative activity help to get programmes such as the NHS health check off the ground.

Making prevention everyone’s business

Some participants expressed concern that making prevention everyone’s business can mean that it is tricky to pin down who has prevention in their portfolio and that no one takes responsibility for key choices and outcomes. Here, we find a difficult balancing act: prevention needs to be part of the day job of more people, but you also need someone or an organisation to oversee the whole system and strategic direction. 

This responsibility should not only be in the hands of one or two impassioned individuals, there needs to be wide ownership, longevity and corporate memory in systems where there is inevitable staffing churn. This responsibility can vary by organisation and system (the CMO, director of strategy, or director of public health may take the lead), which can help innovation and learning between ICSs, but only if the responsibility is clear in each case. For example, we heard of initiatives in Nottinghamshire to identify primary, secondary, tertiary and structural aspects of prevention and use these categories to identify responsibilities and actions, backed up by a strong public health team. We also heard, from the ambulance service, of the value of consensus statements to foster a vision, design a plan, identify key roles for partners and show how to assess progress. 

Using data effectively

Participants described the need to value the process of gathering, analysing, storing, and integrating data. Effective processes require a dedicated data profession and career path (including intelligence, advanced analytics and modelling), a public health profession focusing on the implications of the evidence gathered, and an infrastructure to support this work. These roles are essential to make better use of data on interventions and service performance that are routinely under-analysed or analysed in silos. 

Systems including Nottingham and Nottinghamshire, Greater Manchester, Dorset, Surrey Heartlands, North West London, Frimley, and Cheshire and Merseyside have sophisticated and well-linked-up data through developing population health management capability and capacity. This data-integrated approach to informing commissioning of service, segmentation and risk stratification of populations can connect resources to need and allows systems to be in a better position to ‘make every contact count’.

Hertfordshire and West Essex ICS has a sustainable system-wide research and innovation hub that includes local authority and health analysts, bringing people together for peer support, pooled capacity to seek additional resources, alignment with ICS priorities and aligning data. 

The programme enabled primary care to better support prevention and self-management, with PCNs establishing clinical and operational leads, reviewing data, reducing health inequalities, embedding behaviour-change approaches and strengthening community links.

Effective access to such datasets helps to identify where the demand is coming from, areas of greatest need of intervention and health interventions that work, such as addressing cardiovascular risk via hypertension screening and management. Participants were quick to reflect that just having the data available means little if it is not accompanied by effective skills, infrastructure and incentives to enable its use across the system, and that those capacities are currently spread very unevenly across ICSs. More generally, there are significant gaps between the strategic objective and ambitions from government and the reality of a reduced digital, data and technology workforce to meet these ambitions. One director of public health responded to tales of effective data infrastructure in places like Dorset with a tinge of frustration: 

"I would love for us to do a really coordinated properly funded programme where we ran using our dataset query [to identify patients at risk in a particular disease category]. But I just don't think we've got the capacity and even if I have the money, I don't have the staff to recruit to do that to supplement the staff that are already there.”

Data access and integration are key enablers to drive early intervention and prevention. However, some participants also expressed the need to further develop datasets that segment and risk-stratify populations with multimorbidity and those living with frailty. These are currently not readily identifiable in many existing data sets. 

While quantitative data clearly matters to an evidence-based case, positive qualitative data can demonstrate the impact of prevention work. For example, what did it improve in a person’s life? How many people in an area are not developing conditions, or avoiding harm, following interventions? What would be the financial cost if we don’t act compared to if we do? Can we model future demand to back up this longer-term case? The example of high-intensity user analysis (a small percent of people need a large percent of healthcare appointments) also helps to demonstrate a combined focus on quantitative and qualitative approaches. 

Making the case

Participants describe the need for system leaders to free up space to speak with voluntary sector groups and local citizens to better understand the impact of preventive interventions on day-to-day life, in relation to better homes, jobs and green spaces. 

Nevertheless, many leaders will not engage with prevention-relevant policy problems if they do not see the evidence for interventions’ feasibility. There may be understandable nervousness about new solutions. Here, there is a need to better communicate success stories about, for example, the value of early health detection, or wider initiatives such as pollution control, with particular focus on the benefits of such interventions in specific neighbourhoods. These success stories should connect to information about the progress of promising current projects, such as by using prevention pilots in areas with high levels of deprivation to ask ‘what works well on the ground?’ Piloting and rapid evidence-gathering can help persuade policymakers and enable initiatives to be rolled out on a larger scale. Pilot studies can reshape assumptions and prompt new conversations on data. 

The challenge is that ‘making the case’ pragmatically often runs into the fundamental problems associated with the commissioning model: that pilots are often small-scale, have limited time horizons for impact and lack a secure financial footing to reap real benefits. In this context, participants described the importance of engaging mindfully in split-screen thinking to translate quick wins into longer-term transformation. One promising model explored in the research was the preventive work of the fire service. Here, a slow transition to more preventive intervention – the everyday work of installing smoke alarms, speaking to people about hazards and good practices – has reduced demand and emergency incidences. A positive feedback loop has emerged of greater and more stable investment into the ‘softer’ work of prevention and less need for investment in the hard infrastructure of equipment. 

There is also a need to think differently about how to demonstrate a return on investment for longer-term preventive work by robustly measuring outcomes. System leaders are trying to move away from a reliance on output measures such as referrals towards measuring the end result of the activity, but this also needs to be incentivised by the national financial and performance management regime. 

The idea that preventative interventions always take a long time to deliver impact is a misnomer. This comes back to the intended outcome of preventative interventions. On the one hand this could be to reduce costs, but on a more person-centred approach would be to prevent disease onset for as long as possible, prevent poor-quality care or prevent disability. It could even extend to measures such as completing your life well, having optimal informed choice and control and dying well at the end of your natural life. Preventative interventions for most complex of population segments already living with advanced illness can have demonstrable short-term impact. For example, reducing harms from polypharmacy through higher-quality structured medication reviews (stopping medications identified to be causing more harm than benefit to a person) or advance care planning delivered to populations living with frailty and/or dementia, can significantly reduce rates of hospitalisation. 

Institutionalising prevention

Although prevention is not always congruent with routine government business, it is sometimes possible to change how things are done. The aim is for new strategies, rules and incentives to signal change in the short term then become the long-term norm. First, we heard of the importance of a clear strategy to signal commitment and drive a change of approach. Most integrated care strategies include reference to prevention, population health or health inequalities.

Second, there are ways to build incremental or symbolic spending rises in prevention. In some cases, participants described joint funding pots for specific initiatives, such as to connect thinking on debt support, employment, mental health and disability support. 

One example we heard was the People in Mind programme in Cornwall and the Isles of Scilly, which involves meaningful mental health and suicide prevention work with the voluntary sector, aided initially by a small pot of money that allowed joint ICS work and led to a five-year commitment to co-design and co-commission services with many partners.

Another was Nottingham and Nottinghamshire’s Health Inequality and Innovation Fund, which provides £4 million to foster prevention and equity innovations. The joint forward plan describes a meaningful commitment to increase funding year on year, and wide and continuous dialogue on how to use the investment effectively. The fund is an expression of the ‘guiding mind’ of the health response as well as a symbol of commitment, albeit small in relation to the whole-system budget. This commitment allowed Nottingham and Nottinghamshire to navigate early uncertainty about how to invest and evaluate agreed-upon schemes and retain confident commitment during funding pressures. 

Barriers to shifting to a preventative model of healthcare

Beyond the definition of prevention as a barrier to progression, further discussion helped to identify challenges in key parts of the system or faced by professionals whose responsibility it is to deliver preventative interventions. 

Conclusion

This report has provided insights into the challenges and opportunities of shifting towards more preventative models of healthcare within the context of integrated care systems. 

There were some promising examples of how local leaders are driving forward change against a challenging backdrop. Participants pointed to examples of effective systems leadership, where prevention has become a strategic pillar of integration in which they have embedded integration in governance processes to ensure shared ownership and accountability to make local prevention initiatives everyone’s business. In particular, participants highlighted examples of systems that have been using data effectively to target and benchmark prevention activity, and others in which savvy actors across the system have become adept at making the case for prevention in spite of unpromising circumstances.

Some key challenges emerged from our research. Firstly, system leaders are trying to overcome issues related to congruity by balancing short- and long-term goals to keep prevention on the national policy agenda. Secondly, they are trying to overcome issues related to clarity by progressing an agenda that is seen as important by almost everyone but means many different things to different people. Thirdly, system leaders encounter capacity challenges in securing funding for preventive interventions and then in demonstrating impact from those interventions. The government and national bodies need to ensure there are sufficient incentives to deliver prevention. For example, through system oversight and by looking at changes to payment mechanisms to support a focus on outcomes, and that system leaders have capacity to deliver. Finally, they are attempting to re-engineer services that have been traditionally geared for acute services towards a more preventative and ‘upstream’ model. 

The timescale for impact of preventative interventions is unclear, resulting in the use of short, non-recurrent funding pots on the sorts of preventative strategies that may take far longer to deliver the expected impacts on population level. Looking at allocating shorter-term funding resources for those, often tertiary, prevention measures targeted to the right population group may be a way of unlocking some quicker gains.

Participants were frustrated at what they saw as a rhetorical commitment to prevention from the centre: one which has not been met by positive action. Indeed, successive governments have disinvested in local public services such as the public health grant, housing and social care that contribute negatively to the wider determinants of health. 

There are several things the government and national bodies could do to support ICS leaders to finally shift towards a more preventative model of healthcare. To help overcome issues related to clarity, system leaders want a clearer framework through which they can justify and benchmark meaningful action, while tailoring specific interventions for local needs. The new government’s health mission board could be an opportunity to take a truly cross-government approach, ensuring prevention is congruent with its wider agenda.

The government and national bodies need to ensure there are sufficient incentives to deliver prevention, for example through system oversight and ensuring that commissioning can be done based on outcomes. ICS leaders can enhance their capabilities through some of the suggestions and tools contained in the accompanying practical guide to this report, but nationally they need enough autonomy to spend time and money on prevention, to develop their workforce and to learn from best practice.

Perhaps the loudest and most consistent message was for a concerted effort within the centre to allow ICSs to do more on prevention with their existing funding and to support baselining of prevention spend both locally and nationally to support incremental increases in funding going into prevention. Without this, prevention remains a ‘nice to have’ - something that systems latch on to via short-term grants and pilots. It can be a challenge to maintain focus on prevention within the context of a financial and performance management framework that is focused on activity-based measures such as reducing waiting times. The government’s work to develop a practical definition is welcome and will allow ICS leaders to baseline their prevention spend, in turn supporting a shift in investment towards preventative services. But this can and should be delivered much faster, informed by local definitions that have already been developed.

Several other policy issues were raised:

• Addressing the wider determinants of health will require relevant government departments to work together, mirroring ICSs’ local partnerships. 
• A longer-term and more stable commitment to institutionalising prevention can only happen if system leaders are able to plan ahead and be more agile and adaptable in how they designate funding, working with VCSE and other local partners.
• Data is a key enabler to unlocking prevention. yet the government has not invested in its data, digital and technology workforce.
• There is a great deal of hunger from systems to experiment and to learn from one another, particularly in the context of the constrained environment they are working in. The centre has a key role to play in creating an authorising environment in which leaders feel emboldened to try new things, and a forum in which to share frankly the successes and failures of innovation in trying to promote prevention.