Background: The legislative shift towards integrated care systems (ICSs) in England has made local authorities (LAs) statutory partners, with roles and responsibilities which now go beyond previous jurisdictions. Although these roles and the systems which LAs operate in are complex and changeable, it has been anticipated that more collaborative opportunity would emerge, and that health and care partners could benefit from specific LA insight whilst LAs developed in similar ways. Understanding the local social determinants of health is key to attempts to manage population wellbeing and therefore an effective relationship between different sectors within the system is crucial.
Approach: This paper explores this through qualitative interviews with LA housing partners and attempts to gain insight into the level of engagement within and between sectors. The data were thematically analysed and significant themes included: Type and extent of collaboration, Local Authority structure, Geography, Funding, Housing, Barriers to collaboration or integration and Factors that facilitate collaboration.
Results: Findings revealed a range of cultural, structural and financial barriers which will need to be acknowledged and negotiated in order for reciprocal potential to be realised. Efforts to facilitate integration will need to align with structural complexity where possible. In order for locally focussed integrated care to effectively serve the communities and neighbourhoods as intended in policy, aspects such as housing and equivalent social determinants of health will need to be more well understood, and both structurally and culturally enabled.
Implications: Understanding the value of working beyond conventional boundaries whilst negotiating the perceived difficulties which come with translating and adapting is likely to result in more efficient partnership working and improved outcomes for service users. However the reduction in ICS running costs is likely to make integration beyond core statutory commitments more difficult. Although there is some legislative requirement to collaborate with LAs, specific relationships which respond to population need may be harder to maintain. There is however potential for existing collaboration to supplement and potentially offset the impact of these cuts. A closer consultative relationship between LAs and ICS colleagues may help navigate a period of turbulence and uncertainty. This work offers an opportunity to understand the nuances of cross sector working and is likely to be of relevance across equivalent international integrated care contexts.

Background

In Ontario, Canada, challenges in access to primary care continue to affect patient attachment and equitable health outcomes, including in mixed urban–rural regions. The Frontenac, Lennox and Addington Ontario Health Team (FLA OHT) identified the need for a data-informed, geographically sensitive planning tool to guide local decision-making around primary care attachment and access. Understanding where populations live, their health needs, and where care is provided is central to building more integrated and equitable systems of care.

Approach

This work combined geo-spatial and administrative data to describe the FLA population and model local variations in attachment to primary care, including gaps in population health needs and available primary care services. Data sources included primary care attachment and chronic disease prevalence from INSPIRE-Primary Health Care, sociodemographic indicators from the 2021 Canadian Census (social determinants of health), and the Ontario Marginalization Index. Using Statistics Canada Dissemination Blocks as the foundational geography, an enhanced two-step floating catchment area (2SFCA) method was complimented with spatial autocorrelation to identify and model spatial accessibility to care across the FLA region, and highlight "clusters" where social determinants of health are impacting access and attachment.

Population counts served as the primary access variable (demand), while drive time and provider availability were used as decay functions to model accessibility. The model incorporated the ratio of primary care providers to residents, accounting for both physician supply and practice locations. Resulting catchments were compared with the results of spatial autocorrelation and reviewed with community partners to ensure contextual validity and alignment with local service delivery realities. This collaborative co-design approach informed the process by which the FLA primary care network collaboratively plans using “Health Neighbourhoods”—data-driven primary care catchments that reflect both population need and real-world availability.

Results

Geo-spatial modeling produced distinct primary care catchments across the FLA region that highlight variations in accessibility between urban, semi-urban, and rural areas. These “Health Neighbourhoods” revealed differences in unattached patient rates, provider density, and chronic condition prevalence. Catchment boundaries were intentionally non-contiguous to account for overlapping service areas and cross-boundary care seeking amongst patients.

Preliminary analysis demonstrates that health equity indicators—such as income, housing stability, and material deprivation—should (and do) impact resulting catchment boundaries where spatial distance alone does not equitably represent neighbourhood-level attachment and access to care. The maps provide decision-makers with actionable insights into where population needs are greatest and where interventions could have the highest impact. The model also establishes a reproducible framework that can be updated as new data become available.

Implications

Developing “Health Neighbourhoods” through a co-designed, geo-spatial model demonstrates the feasibility and value of integrating administrative, demographic, and equity data into local health system planning. This approach supports proactive, evidence-based decision-making on primary care attachment and service allocation. Internationally, this model offers a scalable example of how integrated care systems can use spatial analytics to promote equity and optimize resource distribution across diverse geographies. Future work will refine the model through iterative engagement with primary care partners and expand its application to other dimensions of population health planning.

Background: The NHS 10-year Health Plan for England (10YHP) establishes Neighbourhood Health (NbH), which emphasises moving care from hospitals into the community and better integrating teams and a variety of health, social care and Voluntary, Community and Social Enterprise (VCSE) organisations. However, it is currently unclear how this integration and NbH more generally is intended to work. In this presentation we will describe a theory of change (ToC) for NbH developed during the co-design of a national NbH evaluation.

Approach: A series of three co-design workshops were conducted in September and October 2025, with participants representative of a variety of stakeholders: Integrated Care Boards, NHS primary and secondary care, local government, people with lived experience as patients and carers, and VCSE. The first two workshops were conducted online while the third had both online and in-person options. Each workshop consisted of several breakout groups, with group constitution pre-determined to ensure a mix of stakeholders. The workshops were structured based around developing the ToC, starting with initial discussion of what NbH means to people and the barriers and facilitators to delivery of NbH (Workshop 1), then how NbH would work and how would it be known that NbH works (Workshop 2), followed by member-checking the ToC and informing evaluation design (Workshop 3). Break-out group discussions moved iteratively between general NbH to specific factors of NbH. All discussions were audio recorded and online messages during discussions were used to support analysis. Additional data sources, including the 10YHP, were used to support analysis. Analysis and development of the ToC was iterative, moving between: 1) development of an overall theory of change at a more abstract level, 2) identifying more practice grounded ‘pillars’ of NbH that supported the overall theory of change.

Results: Over 100 participants contributed to the process of co-designing an evaluation of NbH. Within each workshop, breakout groups ranged in size from 4 to 8 participants. Drawing on workshop discussions and other data sources, the ToC was developed around six pillars of NbH: 1) Estates, 2) Funding/Financial Flows, 3) Workforce, 4) Data and Digital, 5) Integration and Partnerships, and 6) Patient/Carer

Expectations. The ToC explains the contexts and mechanisms, activities, and outcomes (short-term and long-term). For example, within the data and digital pillar, data sharing was identified as a major component of NbH with multiple activities. An activity example was to incentivise patients to share data, with impacts of this activity assessed by measuring opt-ins/outs and staff feedback.

Implications: Integration of people and services is central to successful NbH. This presentation will discuss how key pillars of NbH were identified and co-design activities were used to examine and develop of a unified ToC and how this could be transferable to other health systems considering or delivering large-scale system change similar to NbH. As the policy and delivery environment of NbH develops over the coming years, the ToC will be refined to inform tangible ways of understanding whether NbH is achieved.

1. Background

The 10 Year Health Plan (2025) signals a new operating model for health and care systems in England. This includes the development of strategic commissioning in Integrated Care Boards (ICBs) alongside the delivery of integrated care in Neighbourhoods. This new operating model requires a rich understanding of whole population health needs in order to effectively commission and deliver care. This presentation describes how strategic commissioning using data and intelligence has led to new models of care.

2. Approach

The approach is structured around 4 stages of strategic commissioning:

a). Understanding local context: A whole population segmentation approach was applied in 2025. This has enabled a more comprehensive understanding of population health by placing the whole population into one of 11 distinct population segments based on health and care needs. Whilst 75% of the population are in population segments that have no or low health needs, 3% are in groups that live with high levels of health need. 'Do nothing' demand modelling has been applied and shown that it is this group (specifically those living with frailty) that will increase by almost 50% by 2040.

b). Developing long-term population health strategy: The segmentation approach (alongside qualitative survey research) is informing local strategic commissioning plans. Three strategic "do something opportunities" are directing the response for this cohort - 1). enabling people to live well for longer (i.e. remain in low need segments); 2). adopting proactive care for people with rising needs (i.e. delay progression into high need segments) and 3). ensuring that the care people is as effective as possible (i.e. value-based healthcare for people within each population segment).

c). Delivering through payer functions and resource allocation: Interventions have been commissioned that respond to these "do something opportunities", with a particular focus on people living with frailty needs. This includes preventative work through the Voluntary and Community Sector alongside the commissioning of models of proactive frailty care within Neighbourhoods (particularly in areas of higher deprivation).

d). Evaluating Impact: The approach uses a range of strategic and operational measures to assess the impact of the "do something opportunities" identified. Whilst commissioned interventions remain live in 2025, the approach describes how measures can be applied to assess the impact of real-world integrated care models.

3. Learning:

Reflective learning has been applied across the four stages to consider areas that could enhance the approach in the future.

This includes:
a). Enhancement to the whole population dataset to more richly understand local population health needs.
b). Further development of citizen engagement in how to respond to identified opportunities
c). Development of contractual and financial models that facilitate integrated care for whole population groups.

4. Implications

This is a practical example of strategic commissioning by taking a whole population health approach. It demonstrates how data and insight can be embedded in the commissioning and delivery of integrated care in local systems. It is particularly relevant for policy makers, those involved in academic research as well as those involved in both commissioning and delivering integrated care.